The CHRISTUS Trinity Clinics Privacy Manager will help execute CHRISTUS' Corporate Compliance and Privacy Work Plans for CHRISTUS Trinity Clinics. The Manager will facilitate the region's compliance with Privacy with both federal and state laws and regulations. Additionally, the Manager will investigate actual and suspected privacy incidents and report findings in accordance with CHRISTUS Policies and processes. The manager helps ensure compliance with privacy regulations and integrity of internal controls; recommends improvements in internal control structure; reviews medical records in the course of privacy investigations or monitoring activities.

MAJOR RESPONSIBILITIES:

Assist the CHRISTUS Director of Privacy with auditing and monitoring business units to ensure compliance with federal and state privacy laws and regulations, including but not limited to Health Information Technology for Economic and Clinical Health (HITECH) Act;

Assist the CHRISTUS Director of Privacy with execution of the CHRISTUS Health System annual work plan, which addresses business risks and exposures related to the healthcare industry, including regulatory compliance and privacy initiatives, the OIG's work plan, senior leaderships' goals and objects, and issues that arise in the course of day-to-day operations;

Work with business units to identify privacy gaps and deficiencies;

Participate in the development of appropriate workflows and corrective actions to address identified gaps and deficiencies. Assist with developing compliance and privacy risk assessments for gaps identified and make recommendations for improvements;

Work with identified departments to develop and implement operational privacy training.

Work with business units to develop monitoring metrics, identify and provide input on department-level policies and procedures, as appropriate, and assist in developing/delivering specialized operational training for department employees;

Collaborate with Information Security Officer or their regional designee to perform annual risk assessments. Assist in the development of a plan for assessing access to PHI and PII by employees, consultants, and business associates;

Assist in the development and/or execution of a complaint workflow so that departments can timely report privacy complaints received from patients, regulatory entities or internal privacy events, to the CHRISTUS Director of Privacy;

Assist in the completion of annual Compliance and Privacy risk assessment processes;

Track Privacy training completion for your area of responsibility;

Ensure Business Associate Agreements (BAAs) are updated within your region and area of responsibility;

Maintain current knowledge of applicable federal and state laws applicable to healthcare privacy;

Maintain rapport with business units to facilitate solid communications;

Serve as a resource for questions regarding application of relevant laws and regulations and the privacy program policies and procedures;

Provide appropriate CHRISTUS Director of Privacy, CHRISTUS Clinic Management Services Compliance Director, and the Vice President and Chief Compliance and Privacy Officer for regional and system board reporting;

Provide or direct compliance or privacy education, as permitted;

Develop and deliver course content for targeted training initiatives as directed by the annual work plan;

Initiate, facilitate, and promote activities to foster awareness of privacy within all entities;

C. Licenses, Registrations, or Certifications

CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.